Young Children, Trauma and Trauma-Informed Systems: What are the Connections with Project LAUNCH?

1. Young Children, Trauma and Trauma-Informed Systems: What are the Connections with Project LAUNCH? Betsy McAlister Groves, LICSW Gail Arnold, M. Psych, LMHC Child Witness to Violence Project Boston Medical Center August 18, 2011

2. AM SessionBetsy McAlister Groves Trauma: what is it? What is a trauma-informed system? Identifying and responding to trauma in health settings PM SessionGail Arnold Assessment tools/strategies Interventions for young children Agenda

3. What Is Trauma? An exceptional experience in which powerful and dangerous stimuli overwhelm the person’s capacity to regulate emotions Overwhelming, often un-anticipated danger that leads to: a subjective experience of helplessness, loss of control and terror Immobilization of usual methods for decreasing danger and anxiety Neurophysiological dysregulation that compromises affective, cognitive and behavioral responses to stimuli

4. A Euro-American, culturally-specific protective shield against massive disasters A Euro-American articulation of suffering and a locus of moral authority Argenti-Pillan, 2000 What Is Trauma?

5. Assessment tools/strategies Research and clinical experience with PTSD carried out in Western industrialized nations Some aspects of PTSD are culture bound; others appear to be universal Cultural context, the “social perception of reality”’ is essential Ethnocultural Aspects of PTSD

6. Trauma & Children: A Short History 1979: Lenore Terr “Children of Chowchilla: A Study of Psychic Trauma” 1952: Bowlby and Robertson “A Two Year Old Goes to the Hospital” 1943: Freud and Burlingaham “War and Children” 1987: Pynoos, Frederick & Nader: “Live Threat and Post Traumatic Stress in School Age Children” 1969, 1973: John Bowlby Attachment and Loss 1947: René Spitz: “Grief: a Peril in Infancy”

7. Trauma & Children: A Short History 1988: Lenore Terr “Children of Chowchilla: A Study of Psychic Trauma” 2011: PTSD in Preschool Children: Proposad DSM V. Diagnosis 1994 & 2004: DCO-3- Traumatic Stress Disorder 1995: Sheeringa and Zeanah: “Symptoms Expression and Trauma Variables in Children under 48 Months of Age” 2000: Perry, de Bellis, Gunnar: Research on Trauma and Brain Development

8. Physical or sexual abuse Exposure to violence in the home Loss or injury of loved one Accidents/dog bites Painful medical procedures Natural disasters Exposure to war/war-related atrocities Trauma Experiences in Early Childhood

9. Young children are exposed to traumatic stressors at rates similar to those of older children. In one study of children aged 2–5, more than half (52.5%) had experienced a severe stressor in their lifetime (Egger & Angold, 2004) In a population of children age 2-18 referred for trauma-focused mental health services (n=1700), the average onset of first trauma was age 5. (Blaustein, Harrison, Van der Kolk, 2003) Epidemiology of Trauma

10. Positive stress: Moderate, short lived; necessary for growth Tolerable stress: Occur intensely for brief periods of time; the brain recovers Toxic stress: Chronic, uncontrollable, occurring without the child having access to supportive adults Shonkoff, 2006 Excessive Stress & the Developing Child

11. Stressful events can be harmful, tolerable or beneficial, depending on: Whether the stressful experience is controllable How often and for how long the body’s stress system has been activated in the past Whether the affected child has safe and dependable relationships to turn to for support. Shonkoff:, 2006 Stress and the pre-schooler

12. Behaviors Associated with Early Childhood Trauma Ages: 0-2 Dysregulated eating, sleeping patterns Developmental regression Irritability, sadness, anger Poor appetite; low weight Increased separation anxiety; clinginess Ages 3-6 Increased aggression Somatic symptoms Sleep difficulties/nightmares Increased separation anxiety New fears Increased distractibility/high activity level Increased withdrawal/apathy Developmental regression Repetitive talk/play about the event Intrusive thoughts, memories, worries

13. Early Childhood Trauma Affects: • The brain • Architecture • Neurochemistry • Attachment

14. Severe Neglect Bruce Perry, 2001 Chronic or toxic stress affects brain development

15. Chronic Traumatic Stress affects the Neurochemistry of the Brain

16. Primary motivations Attachment Exploration Trauma disrupts the process of learning to trust significant caregivers and thwarts exploration Development of fear The Impact of Trauma: A Developmental Framework

17. Winnicott: “There is no infant without the mother” Scheeringa & Zeanah, 1995: The best predictor of severity and the only variable associated with higher rates of PTSD was trauma involving a threat toward the child’s caregivers. Laor: Maternal avoidance symptoms predicted worse child outcome than other symptom criteria. The Relational Context of Early Childhood PTSD

18. What is a trauma-informed system of care?

19. A trauma-informed system: Is knowledgeable about the experience of trauma, traumatic impacts, health and mental health implications; recognizes and understands the impact of traumatic experiences on the functioning of adults, children and families Offers services in ways that will maximize the client’s sense of safety, control and predictability. Recognizes and manages secondary trauma/vicarious stress in staff or workforce

20. Essential elements of a trauma-informed system A common knowledge and language to recognize and respond to clients affected by trauma Common language and practices around safety and predictability Expectations for the client Expectations or responsibilities of the provider Consumers are partners and have a say in their service delivery

21. PTSD-related behaviors that may interfere with clients’ abilities to access or utilize services Clients see the world as potentially dangerous and unpredictable Clients are easily triggered by reminders of traumatic events Clients may appear to be numb or detached Clients may have difficulty with memory, sequential organization of information Clients may display rapid mood/affect change: becoming upset or angry very easily

22. A Training Module developed by the Child Witness to Violence Project and the Division of Developmental and Behavioral Pediatrics/ Boston Medical Center If You Don’t Ask, They Won’t Tell Identification and Management of Early Childhood Trauma in Pediatric Settings

23. Acknowledgements National Child Traumatic Stress Network: Special Projects Grant Harris Foundation Our colleagues at Boston Medical Center: Michelle Acker, Psy D. Marilyn Augustyn MD Jose Alberto Betances MD Vincent Licenziano, MA Bob Sege MD Barry Zuckerman MD

24. Teaching Points Young children are highly aware of their environments and can be affected by stressful and traumatic events A parent’s response to traumatic stress is often the strongest predictor of the child’s response Early identification of child traumatic stress is a powerful form of intervention Pediatric practitioners have a choice of interventions if a young child has been exposed to a traumatic stressor, ranging from in-office support and guidance to making a referral for mental health services.

25. Pediatric Management of Early Childhood Traumatic Stress Inquire about stressors in the child’s life. Has something scary or upsetting happened to your child recently? Have there been changes in your child’s life? If parent has concerns about changes in child’s behavior: What do you notice about changes in your child’s behavior? When did this start? What was happening at the time? Provide developmental guidance about trauma response Provide education/guidance about behavior management , routines and daily living activities to promote recovery and sense of safety Refer for mental health intervention, if needed Provide close follow-up and ongoing monitoring

26. Case Study: Alyssa 4 year-old girl; single parent family Alyssa’s school is concerned about her behavior Dr. Betances knows the family This is a “problem visit”

27. Dr. Betances’ Intervention Building rapport Mom: “The school made me come in.” Listening to the story Dr. Betances: “I had no idea.” Identifying the stressor “When was the last time the school had any discussion with you about Alyssa?” “Have you noticed anything different at home?”

28. DILEMMA Should the child be in the room … or not?

29. Dr. Betances’ Intervention Developmental guidance Exploring the meaning of Alyssa’s behavior Talking about how a 4-year-old copes with the sudden loss of a caregiver “You might be able to explain to her—even just a little bit at a time…” Parental support “Are you seeking support for yourself?”

30. The parent’s response is closely linked to the child’s response “We actually have two patients in the room.” “Sometimes the parent is going to be the harder sell.”

31. Alyssa—Follow-up Plan Return in 6 weeks Encourages mom to talk with Alyssa’s teacher Wrote a note to the school

32. Pediatric Management of Early Childhood Traumatic Stress Inquire about stressors in the child’s life. Key questions: What do you notice about changes in your child’s behavior? When did this start? What was happening at the time? Provide developmental guidance about trauma response Provide education/guidance about behavior management, routines and daily living activities to promote recovery and sense of safety Refer for mental health intervention, if needed Provide close follow-up and ongoing monitoring

33. Screening for Trauma Exposure in Pediatric Settings “Since the last time I saw your child, has anything really scary or upsetting happened to your child or anyone in your family?” Cohen, Kelleher, & Mannarino (2008)

34. Pediatric Emotional Distress Screening (PEDS) For evaluating children age 2-10 who have been exposed to a traumatic event within the past year 21 items, rated by parent Items rated 1-4: “almost never” to “very often” Higher score = greater distress Saylor CF, Swenson CC (1999)

35. UCLA PTSD Reaction Index Parent Screening Version Brief screen for PTSD symptoms Children aged 0-8 who have been exposed to a potentially traumatic event Six items, rated by parent Pynoos, Rodriguez, Steinberg, Stuber, & Fredericks, (1999).

36. Screening Tool for Early Predictors of PTSD (STEPP) Brief, stand-alone screening tool consisting of 12 questions, developed for use during acute trauma care to assist in identifying at risk children and parents Developed for use in Emergency Department; could be used in other settings. Winston, Kassam-Adams, Garcia-Espana, et. al (2003)

37. When to refer a child for mental health services… When the symptoms persist for more than one month When the parents are unable to be supportive or attuned to the needs of the child When the parent is highly distressed and symptomatic When the trauma involves the sudden or violent loss of a caregiver or family member

38. Alyssa’s Mom: “What can you do for a four-year-old”? Treatment for Traumatic Stress Response in Young Children: Child-Parent Psychotherapy (CPP) (Lieberman and Van Horn, 2005) Preschool PTSD Treatment (Scheeringa, Cohen and Amaya-Jackson, 2002) Parent Child Interactional Therapy (PCIT)

39. Goals of the Treatment Enable parent to understand the child’s response and to respond appropriately Manage behavioral symptoms Provide child the opportunity to share his/her perspective about what happened: fears, attributions, cognitive distortions.

40. Contact Information & Helpful Websites Betsy McAlister Groves, LICSW Child Witness to Violence Project Boston Medical Center Vose 4 Boston MA 02118 Tel: 617-414-4247 E-mail: betsy.groves@bmc.org National Child Traumatic Stress Network: NCTSN.org Center for the Developing Child: www.developingchild.net Child Witness to Violence Project: www.childwitnesstoviolence.org US-DOJ—Safe Start Center: www.safestartcenter.org 40 40